All posts by Susie Simpson

Complicating the Obvious or Why a Duck is a Duck by Peter S. Kibbe MD FHM

 A  doctor and a duck walk into a bar and the bartender says that they don’t serve ducks.  So the doctor says, “This isn’t a duck!” and… well, more on this below.

A physician friend of mine recently proved that he understood the saying that a physician who treats himself usually has a fool for a patient.  He showed me a picture of a rash he had developed a few days earlier on his arm.  He explained that he at first attempted to ignore it, then called his personal physician and sent the cell phone image of the rash to him.  My friend thought it was a rash typical of Lyme disease and his physician agreed that of course, it was and could be nothing else and immediately prescribed the proper antibiotic.  My friend was working in the woods around his house, developed the rash, malaise and fever.  Almost no other infection has that typical rash as a sign, none in an Ohioan who has not been traveling to the Southwest of the U.S.  It could be nothing else.

All laboratory tests at this point would be academic.  It is what it is.

Many clinical syndromes present this way, glaringly obvious from the history and physical examination alone, yet we appear, at least in the environments where I practice, to complicate them for our patients.

I would argue, as have many,  that much of the testing, imaging and other diagnostics we order for patients should be seen as a burden we place on them.  This burden can be emotional, engendered by anxiety and fear while awaiting the test results, and as well it can be a physical burden—the radiation delivered with CT scanning, the physical discomfort experienced with certain imaging procedures or the negative consequences of the sedation required for certain procedures.

Being placed in a hospital bed can be a burden as well in terms of financial loss, lost time, disturbed sleep and dietary patterns and, for the elderly, the rapid deconditioning they experience by being made immobile.

Not long ago I was referred a patient for admission for observation who, I was told by the emergency department clinician, had experienced a syncopal episode while standing in her kitchen.  She was a very healthy and active 80-something whom I encountered with her husband.  The history was a bit more complicated but the history alone pin-pointed the cause of her brief faint.

She, for several months, had been experiencing severe pain in the right hip, a joint that had been replaced several years prior.  The pain was not a problem when she was active and did not interfere with her  routine of daily and very long walks.  She got in a couple of miles or more.  She loved to cook and she found that after prolonged standing at her kitchen counter the pain would become disabling.  It was relieved by sitting and when I first encountered her she was pain-free.  On the day of her presentation she was making one of her complex culinary favorites when the pain began and it progressed.  Her husband found her in distress, standing and grimacing, and as he helped her to a chair she briefly lost consciousness without any other sign or symptom, and then very rapidly awakened.  The inevitable CAT scan of her brain was obtained which was negative.  She was fully ambulatory. Her vital signs were normal.  Her hip was not tender.  Her past medical history was, other than bone and joint problems, a blank.  Her electrocardiogram was normal.

So, how could placing this person in a hospital bed tethered to a cardiac monitor be to her benefit?  It could not. Radiating her head would not help either.  She had an orthopedic problem which caused a vasovagal syncope.  Intense pain often causes the blood pressure to drop, cerebral perfusion transiently drops, brief syncope ensues.  My old chief of medicine used to call these “house call” or “black bag” cases, meaning all you need to sort things out is your brain, a stethoscope, a sphygmomanometer, maybe a reflex hammer and light source.

In complicating the simple we often  forget the old saw that “If something looks like a duck, walks like a duck, swims like a duck  and quacks like a duck,  it probably really is a duck.

 

The Dutch Cousin – Peter S. Kibbe, MD, FHM

Now and again I see in the press a report regarding physician-assisted suicide or legislation proposed to enable the same.  The arguments for and against stir little passion in me, but they do provoke memories.

In a North Carolina hospital where I practiced some years ago there was a native Carolinian obstetrician, experienced, bright and very grey and gangly.  He had the North Carolinian capacity to tell a good story, to “hold forth,” to capture a group of doctors in the doctors’ lounge with a story, often humorous.  I loved to listen as, draping his thin frame of close to seven feet across an arm chair, he entertained us.

One day he rambled in as some of us were drinking coffee or pecking away at the computers, threw himself into a chair, and told us about his recent phone call with a friend in Holland.

He was of Dutch extraction (although you could not tell from his drawl), spoke the language and maintained family connections in Holland.  “I just got off the phone with a friend in Holland who told me about a cousin of mine.  Told me they were going to have a wake for him this Saturday. He said he knew I probably couldn’t make it, but he just wanted me to know.  Well, I said, ‘Hell, I didn’t even know he was dead yet.’ And he told me that he isn’t dead yet, but he is going to die on Friday.”

Then he explained that his cousin had a very advanced, painful and untreatable malignancy and was taking advantage of the Dutch laws which permit patients such as his cousin to employ physician-assisted suicide.  A discussion followed regarding how practical the Dutch were, how they respected human rights and that this man was exercising a right to exit the world of pain in which he was living at a time of his choosing.  There is much to be said in respect to that argument.

I have other memories, although not many, of certain patients living in such horrible pain, untreatable pain, whose lives I might have assisted them to end without a shred of remorse.  I recall a man whom I cared for in a nursing facility who had the most painful form of dementia I have ever encountered.  He was completely unaware of his external environment, fed through a PEG tube, bed-bound and unable to speak coherently.  Worse than any of those impairments, his dementia had rendered his psychic or cerebral environment into some kind of never ending hell.  He screamed and wailed whenever awake, as though some harpy were pulling at his entrails or as though he were on some psychic rack which was tearing apart his cerebral bones and joints. I could find no source of physical pain.  I treated him with a psychiatrist and our only recourse was to keep him so sedated that he was barely ever truly awake.  When he broke through the sedation the howling would renew itself, his tormentors would return, the fires of his psychic hell would flare.

Opportunities presented themselves for him to exit the earth with some dignity—a pneumonia or some other infection, and I advised his wife that we should treat him only with whatever comfort measures he appeared to need.  She was adamant that he be kept alive and be bundled off to the hospital.  I felt that I had become a conspirator in torture and battery. I wondered if he had beaten and abused her.  Was this her vengeance?  In fact, I stopped attending to patients in nursing facilities because of this and similar cases.

Regarding physician-assisted suicide, the line is thin between the admitted and controlled fact of how the Dutch do it, and the de facto fashion in which we often employ palliative morphine to prevent discomfort in the dying patient.  We all know that when someone is dying and is uncomfortable it is often best to exit the earth in the arms of Morpheus, oblivious to suffering.  Yet are we helping the dying soul by permitting Morpheus to slide the patient off into the netherworld? At times I do not know.  It does not rise, for me, to the level of a moral argument.  It is a more viscerally or perhaps soulfully determined act.  As my father-in-law, an eminent physician would say of certain cases, “It is time to bring out the morphine.” Most of us know when that time comes.

As to whether we in the United States could enact legislation to permit physician-assisted suicide, I doubt we could do it. Some states have passed laws that permit what they call medical aid in dying, but a national consensus is probably not possible. We lack the practicality of the Dutch. We cannot do the work to save and preserve New Orleans or Houston from the storms we know will strike them, while the Dutch have been preserving their land from crippling water catastrophes for centuries.  If some part of their landscape is likely to flood, they won’t allow buildings there.  They turn those areas into a space, such as a park, which could capture flood water and still have human use when dry.  We build again and again on landscapes predictably endangered.

Could Americans fashion a way for people such as the Dutch cousin to make their exodus reasonably?  As in the way we attend to New Orleans we would probably muck it up. In the end, Americans in general would rather go to Disney Land.

Peter S. Kibbe, MD, FHM

Driving a Screw With a Hammer Peter S Kibbe, MD, FHM

August 1, 2018

I have worked for some years now with hospital administrators who use HCAHPS scores of individual hospitalist physicians as indicators of the communication performance of these individuals.  I have worked also with some who use the scores of an entire group of hospitalist physicians to judge the communication performance of the group.  Both of these approaches are flawed. 

As Leslie Flores points out in a June edition of the official blog of the Society of Hospital Medicine, “Regulators never intended HCAHPS to be used to evaluate the performance of individual doctors, nurses or other hospital staff, or to attribute scores to any physician (or physician group)….HCAHPS is not measuring you on your patient experience performance, contrary to what many of you are being told by hospital and health system leaders.” (emphasis the author’s)

The fact that these scores are not useful in evaluating individuals or groups of individuals such as hospitalists seems self-evident by the manner in which groups of doctors care for individual hospital patients.  We know that the majority of our patients come through the emergency department where they see a doctor and they might then be admitted by one of our group members, then seen by a consulting physician, then be seen and discharged by another member of our group of hospitalists.  The usual method of assigning a physician to be “responsible” for the patient’s responses to the questions on the survey regarding physician communication is to assign the responses to the discharging physician.

In a research paper on physician coaching and its effect on patient experience, Sieler, et al. point out that studies show that less than a third of hospitalized patients can correctly name their physicians.  They also point out that in one large study the discharging hospitalist physician was responsible for only about one third of the patient’s physician encounters.(1)

Some hospital administrators fashion “work arounds” in order to attempt to make the HCAHP surveys reflect individual physician communication performance.  They might insist the discharging hospitalist physician inform the patient that the survey questions regarding “the doctor” are a reflection only of the discharging doctor.  They might also adopt the position that the group of hospitalists is uniquely responsible for raising the scores of the entire hospital medical staff.  They also often publicly publish individual physician scores.  They often financially incentivize hospitalist groups according to their scores.

This is like attempting to drive a screw with a hammer. 

In a May, 2016 JAMA article, 3 CMS officials including the CMS Chief Medical Officer make it clear that HCAHPS surveys were designed to give hospital administrators an aggregate, not individual, picture of patient perceptions.  “Although designed to measure hospital-level performance, some hospitals may be disaggregating their raw HCAHPS data to compare, assess and incentivize individual physicians, nurses and other hospital staff…there are reports that some hospitals link individual physician or physician group financial incentives to performance on disaggregated HCAHPS responses.  This is contrary to the survey’s design and policy aim.  HCAHPS is not suitable for evaluating or incentivizing individuals or groups within a hospital.” (2)

An attempt to raise physician scoring, therefore, cannot be accomplished by attempting to reward or punish individuals or groups.  Improving the patient communication skills of a hospitalist group is laudable but insufficient if the same excellence in communication skills is not expected of all the facility’s physicians and staff.  If the culture of the hospital is consistent with providing a platform for physicians who perform procedures without consulting with and communicating well with attending physicians and the patient and families—working as a team to get to what is the best for the patient—hammering away at the individual scores of hospitalists will not be successful.

Changing the hospital culture of communication is often the indicated measure.  I would argue that it not only includes improving physician communication skills but demands excellent communication among clinicians.  If a consultant is relatively mute in explaining to patients, it is highly likely he or she will be the same with his or her colleagues.

  1. Physician communication coaching effects on patient experience, Adrianne Seiler, et al., PLOS One, July 5, 2017
  2. Measurement of the patient Experience

      Clarifying Facts, Myths and Approaches, Lemeneh Tefera, JAMA, May 24,   2016

The Patient is Not a Complaint — Peter S. Kibbe MD FHM

“Nothing will sustain you more potently than the power to recognize in our humdrum routine… the true poetry of life – the poetry of the commonplace, of the plain, toil-warn woman, with their joys their sorrows and their griefs.”  – Sir William Osler

At morning rounds recently I listened as a first year resident presented the case of a young woman admitted to the hospital.  As the presentation became more complicated by a curious past history I interrupted and asked, “Who is this person?”

The other residents stared in silence.

I explained that a nurse care coordinator who I had worked with would always pose a similar question when presented with a new case during rounds. If we were discussing an elderly patient who had been admitted with diverticulitis, she would ask, “Does she have anyone who loves her?”

Her question asked if we had identified anyone who helped this person through life.    The answer involved finding out about the person, asking questions or “going to where the patient lives.” So the “who” of the patient I was concerned about was a request that the resident delve into the patient’s “narrative,” her life.    Was this young woman married, did she have a partner, have kids, go to school, did she work, care for an ill parent, had she gone to college, did she like her job, hate her job?  What was her affect? What were her fears?  If the patient has obvious impairments who helps her—who loves her?

When I was in medical school a world famous rheumatologist on our faculty would comment on his patients during rounds by first describing them psychiatrically.  I can still see him at grand rounds, looming large in front of the crowd of staff and students, cigar in hand describing the personalities of the people he treated.  He did so for good reason.  He understood how their personalities and psychiatric profiles colored how they cared for their individual chronic illnesses.  Some were passive aggressive, some depressive, some outgoing.  They were people.  They were souls.

No one suffers illness that is not contextualized by who they are and where they stand in the complex social arrangements of their lives.   Recently I was rounding with residents who were getting ready to discharge a man in his middle fifties who had had some complications from gall stone pancreatitis following surgery.  This was my first encounter with him and I asked him about his life.  He had recently lost a job, was divorced with no children, shared a rental apartment with a roommate, had no car and had medical insurance through Medicaid.

As we were walking down the hall I asked the two residents I was working with what they felt about his life and they seemed bewildered.

Given what he told me, I explained that I saw this man’s life as “Precarious.” A lone, unemployed man in middle age with no assets and no social support structure always makes me worry. It should raise their eyebrows as well. They must see the whole patient. There is a lot of “precariousness” going about these days.

The social history should not be just a series of questions.  It has been boiled down to questions regarding illicit drug use, smoking and drinking alcohol. The functional pressure of the physician to get the patient processed cannot explode the art of using the history of the patient to guide the treatment and diagnostic course.  This pressure is partly due to the transformative effect of the electronic health record in which the clinician role is warped into a data entry job—one seeks out, in communicating with the patient, what one must point and click in the patient note formats.  The patient becomes a complaint, a problem list.

I would further argue that many of the work environment demands bearing down on the physician in the hospital (quality metrics, billing metrics, coding metrics, use of order sets metrics, attestations, time metrics for discharge, individualizing physician patient  satisfaction scoring, stroke alerts, sepsis alerts) may have negative quality effects on patient care, as they vampirically suck out the physicians’ time.  Every moment a physician has to spend feeding the beast with a screen is a moment of patient communication lost.  Often a piece of information from the patient or the family, if one has the time and technique to get to it, alters dramatically a course of therapy or diagnostic planning. 

Burdens that come from above and onto the shoulders of physicians and nurses arrive without much concern or investigation about whether the clerical or procedural burdens, multiplying each year, can reasonably be born.  In many instances their benefits are not very clear.

Black humor abounds regarding the situation, such as the characterization of a physician’s hospital life as a “death by a thousand clicks.”

Perhaps the time for humor is over. Perhaps it’s time for revolt. We have people to care for, souls to assist.

 

 

 

 

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Going Third World

            When I walk along your city streets and look into your eyes
            When I see that simple sadness that upon your features lies
            If my spirit starts to sink it comes as no surprise
            It’s been a long way from anywhere like heaven to your town, this town
                                                                              –   James Taylor, Anywhere Like Heaven

Some years ago I worked at a hospital in a unique small city on the inner banks of North Carolina.  With a population of only about 30,000 and at an inconvenient distance from the more swank and upscale centers of the North Carolinian economic boom regions (Raleigh, Durham, Chapel Hill, Charlotte) the city had nurtured the growth of a very respectable hospital that served the needs of a population of 100,000 people.

The quality of care was really good, I would say better for many conditions than the quality of care in Cleveland, where I work now.  Although we could not offer certain services that were cutting edge and could not pretend to be a tertiary care center, the rapidity with which patients were sorted out and cared for was remarkable.  The hospital was also free from much of the political infighting and turf wars one encounters in the Cleveland area, and that was probably a reflection of the fact that all of us who were physicians and surgeons were stuck with one another and had to find the means to cooperate to the patients’ benefit.  The chief medical officer was not so much interested in whether you as a physician brought patients to the hospital or not. He had an uncanny way of addressing problems by systematically looking at them and bringing everyone who had a part in a solution together.   Performance and patient safety were valued above market share.

That said, the surrounding rural communities, particularly at the periphery of our catchment area, were medical care deserts.  Historically this region had always been poor.  Indeed, one local historian noted that at the beginning of the European conquest of the region it had tended to attract people with little cash and coin, because they could sustain themselves from the abundant aquatic life and the fertile soil.

So physicians in the countryside were always scarce and the poverty was remarkable.  Anyone who imagines that legions of poor people subsist on welfare checks for life should disabuse themselves.  For decades supplemental cash support for the impoverished has basically not existed and North Carolina appears to have taken a certain pride in how little it supports a public health infrastructure and how little it supports public education.  Obtaining medical insurance via Medicaid is very restricted and the North Carolina politicians have proudly refused to expand Medicaid coverage in spite of the fact that the Federal government would foot the bill for almost all of an expansion.  My sense of the general situation of the wealthy and poor in that region was that the very poor worked very hard just to be poor.

I experienced an evening of clarity regarding this when a friend of mine, a nurse in retirement, invited me to become the supervising physician of a free clinic run once a week in the county public health offices of a small community near the coast of the inner banks.  She had recently agreed to become the clinic director.  While I had to tell her I most likely would decline due to time constraints I did agree to drive down to see what one of their evening clinics were about.

It was in a community with a main street, down at its heels, a courthouse, some gas stations, some fast food outlets and empty buildings.  Like much of the housing in those environs, the trailer home is ubiquitous.  The landscape is flat and agricultural and from the road out of town the vista affords views of an occasional well-kept vegetable garden and seasonal roadside stand contrasting with collapsing old farmhouses beside questionably habitable trailers.

I arrived at a tiny set of offices jammed with people who were standing, packed in corridors, waiting rooms or smoking in the darkness of the parking lot, waiting for encounters with physicians who were all retired, one a robust man of 80 years.  I was much amazed at the sheer number of patients. Then they waited at the make-shift pharmacy run by a retired couple who were pharmacists and who had, as if by magic, stocked the room from floor to ceiling with common medications they had obtained through various connections with industry.  All medications were dispensed free of charge. The clinic had an agreement with the hospital where I worked in which lab tests and simple x-rays could be obtained via the hospital free of charge.

The people were pleasant and polite and racially mixed.  Their facial expressions were varied, but fatigue and sadness seemed predominant.  They were poorly clothed and their vehicles in the parking lot, essential property in a region with no public transit, had seen much better days. These were of the expanding class of American working poor.  Most of the patients were middle aged, most were there to control their diabetes, hypertension, asthma and heart failure.  The clinic was held at night because these were working people with no medical insurance to cover what they could not possibly pay for, and jobs which, I suspect, would not allow them a few hours off to see a doctor. Do not mention the health of their mouths or their eyes. Like many Americans these are people who almost never have dental disease treated.  For most of the patients whose oral cavities I examined it appeared that they lived most of their lives with a mouth of deteriorating, infected dentition.  Their plans for dental care were to wait for the day when they had the money for full extraction and the creation of dentures at one of the well-advertised denture clinics one spots on the highways.

I left that evening with both an admiration of what the community was trying to accomplish and a deep sense of dread, a sinking spirit, a sort of foreboding.  Before me there was fact, revelation that American civilization is fading, its multitudes of poor slipping into the status of the poor of what we used to call the Third World.  Like some community of the Third World, desperately this little community was trying to claw its way, in terms of basic medical attention, into the twentieth century, in the early years of the twenty first.

Civilization depends upon taxation.  In western culture this has been understood since the ancient Greek philosophers pondered questions regarding politics and citizenship.  From taxation flow the funds through which good governance provides for what our constitution names as a bedrock responsibility of the government it establishes—the general welfare of the people.  We have now arrived at a place where a tiny few enjoy unimaginable wealth and see their taxes dramatically diminishing.  For them the economic question might be where to buy their next extra luxury house.  For a growing multitude the economic question is more like where they might find the heaven of any decent dwelling, more like where they might find their next bag of groceries or when they might find the money to have all their teeth extracted.

 

She That Shall Live This Day, and See Old Age…

In Shakespeare’s Henry the Fifth King Henry rouses and encourages his troops to do battle with the French at Agincourt.  In the famous “band of brothers” speech he assures his men that “he who sheds his blood with me today shall be my brother.”   He also assures them that posterity will not forget what they do that day, a day in the Christian calendar known as St. Crispian’s Day:

This day is called the feast of Crispian.
He that outlives this day, and comes safe home,
Will rouse him at the name of Crispian.
He that shall live this day, and see old age,
Will yearly on the vigil feast his neighbors
And say “Tomorrow is St. Crispian.”
Then he will strip his sleeve and show his scars,
And say, “These wounds I had on Crispian’s Day.

I was reminded of this scene when I recently cared for a very elderly lady referred to the hospital by a hospice facility.  The hospice physician thought she was having problems that he could not control for her comfort and wanted us to do some hospital diagnostics to help clarify her condition.  He had no access to her past records because she had always been cared for via the Veterans Administration system.

She was the oldest female veteran of the second world war I have ever met, a 96 year old who, although her mind was not clear,  assured me the moment I met her that, “The War Department will take care of me.”  Since the U.S. Department of Defense has not been called the War Department since before I was born, her use of the term intrigued me and I asked her in which service she had served.  She told me that she served in the United States Army.  When I asked her where, she said “Tunis.”  She also said that she had served with bomb reconnaissance.  Her mind wandered and she began to tell me about a dog who was named Yorky Doodle Dandy and how the dog had done some things that were unintelligible to me, including being taken to Hollywood, and her mind drifted off.  I did not press her. (I do not expect to be alive at her age, let alone to be able to communicate coherently.)

I remember that when I was a boy my father told me about bombing the harbor at Tunis from his U.S. Army Air Corps base in Algeria.  It was held by the Germans, who were of course forced to surrender.  So I went to the Wiki and discovered that, indeed, shortly after the city of Tunis was in the hands of the Allies a large bomb reconnaissance group was sent to the city from Britain.  These people were women and men who for whatever reason—be they artists or archaeologists—were very good at looking at photographs of enemy territory taken from airplanes at high altitude and figuring out what the tiny images represented.  Since after the Germans left North Africa the Allies would begin to invade Italy, which involved a great amount of bombing, the reconnaissance work in Tunis went on for over a year.

And what of the dog?  It turns out that a Yorkshire terrier was acquired by a photo reconnaissance soldier in the Pacific theater and became famous for the tasks he could perform, sometimes under enemy fire,  to assist the soldiers.  That soldier, named Wynne, was from Cleveland and he named the dog “Smokey.”  He was also known as Yorky Doodle.  “Smokey” was allegedly a reference to the  then very much polluted skies of Cleveland. Wynne brought the dog back to Cleveland and wrote a popular book about the creature.  The dog was so famous that there is a memorial to it at the Cleveland Metroparks in Lakewood.

If you listen to the elderly patients, even through their dementia, at times they will connect you to a past that is still vivid in their memories, memories accurate in spite of loss of cognitive ability and the passage of three quarters of a century. These will often relate to the most vivid, perhaps horrid, perhaps exciting times of their youth.  They engender in me at times a respect—for bravery or diligence or the simple will to survive and be able to testify.  I have heard the stories of old African Americans who lived through the Jim Crow south, of soldiers who as mere boys stumbled on a German concentration camp and weep at what they saw, of steel workers who endured the strikes of the depression era and emerged bloodied but victorious.

This patient was soon discharged and I was left to wonder if she had gone from Tunis to the Pacific theater, if she had worked with the owner of Smokey.  What had she been trying to say?  Certainly the important roles that women played in the war have gone relatively untold compared to those of the men and I wish that I had been able to expand her story.

Certainly, and virtually on her deathbed, she was stripping her sleeve and showing her scars. Her military days must have been fraught with the dangers of war zones but also the excitement and wonder of a military and international experience.  She engaged in world travel in an era when that was virtually impossible for most Americans and included the exhilaration of transAtlantic crossings and air travel that probably in her most fantastic dreams she would not have contemplated as a girl before the war.

She had lived the day and seen old age.  Women from “The Great Generation” are dying off.  Few remain to tell us as living historians of their own St. Crispian’s Day.

 

The Eyes Have It – Peter S. Kibbe, MD, FHM

When I shadow other physicians on their rounds I am sometimes struck by the variability of the social skills the physicians demonstrate.  The most skilled have a manner of speaking, a tone of voice, a rhetorical capacity and body language as well as facial expression—a demeanor, perhaps— that ingratiates the patient.  These skills invite the confidence of the patient and give the patient permission to reveal, often rapidly, the intimate details of their lives.  At times I wonder when I watch these excellent communicators work if what I am really observing is an actor or a con artist at work.  I have seen this  in all walks of life that require intense communication and relational skills. I am wondering if these skills can be learned or if they are attributable to some genetic sequence, already or soon to be discovered?  This leads me to recall the skills of my eldest daughter, Rachel.

When she was very young, around seven or eight years old, my wife and I noticed something a bit startling.  If we went out for an evening and hired a baby sitter, the following day she would be able to tell us in great detail all about who the baby sitter was.  The babysitters, almost exclusively teen age girls, would put her siblings, toddlers at the time, to bed early, then sit up for some hours with Rachel.  The curious thing that we noticed was that my daughter, even if she had never met the baby sitter before, appeared in an evening to come to know her well and could tell us about intimate details related to her life—school events, relationships with boyfriends, problems with her parents, her aspirations and fears.

This became something of a joke between my wife and me.  We knew that whenever we hired a babysitter for the evening the following day we would learn far more about her than we cared to hear.  Yet, looking backwards, this wisp of a daughter had been prematurely verbal, very garrulous and socially engaging. I do not think she learned these skills; her capacity to be disarming and charming, able to make a teenager feel that they were old friends and to quickly form a sort of intimacy and mutual confidence. It turns out that her talents probably were in her ability to read a stranger’s face.

I am reminded of the work of Oliver Sacks, a neurologist and writer who sadly died a couple of years ago, a physician who was fascinated by the brain but also by people.  He left us with volumes of insightful writing about neurological syndromes and the people who suffered from and dealt with them. One group of people he wrote about and videoed had Williams syndrome.

People with Williams syndrome have a rare genetic disorder that expresses itself with a mixture of physical tendencies, facial features, neurological defects and superior skills.  They tend to have elfin eyes and rounded noses.  They have a higher incidence of certain cardiac anomalies.  They are virtually anumeric, unable to sort numbers at all and they cannot comprehend simple spatial relationships.  If you draw a simple cross and ask them to reproduce it on paper they might draw an L-shaped figure and be perfectly convinced that they have succeeded.  Yet they are musically very adept, verbally highly skilled and socially they can make strangers think after a few minutes of conversation that they have been BFF’s.  In a typical video, Sacks walks hand in hand with a girl who has the syndrome, about ten years of age, into a sandwich shop she had never visited and within minutes the girl is sitting on the counter making friends with the waitresses and cooks, almost working the crowd as if she were the favorite neighborhood child come home from a long period of absence.

In my admittedly brief research on these Williams syndrome people I have discovered that they make eye contact with other persons much more intensely than the average.  Anecdotally I have almost always associated that behavior with the best physician communicators.  Looking someone in the eye implies the observer is reading the face of that person, and that is a quality or a capacity, an intelligence that can be measured and which some researchers link to social intelligence.  It appears to be inherited; identical twins share that capacity or lack of it more than non-identical twins, as do persons with Williams syndrome.

The question that arises for anyone who tries to teach communication skills is whether the ability of reading a human face for emotional content can be taught.  In other words, can the skill of one physician in reading anger or anxiety in a relatively subtle facial expression be taught to another whose visual cortex is relatively “blind” to facial expression?

It turns out the answer is affirmative and there is a huge area of scholarship surrounding this.  Darwin asserted about a century and a half ago that human facial expressions are universal and cross all cultures.  This has been widely accepted, and researchers have also  divided facial expressions into two groups, those that are maintained for a few seconds and those that are formed for as little as one thirtieth of a second.  These latter “microexpressions” appear to represent emotions that are difficult to suppress. Logic would suggest then that creating a favorable rapport with a patient would entail, in part, a keen eye for what are almost, perhaps, subconscious facial expressions and then molding communications to correspond to and deal with those emotions. That skill just might trump all others.

So should medical schools be employing psychologists who specialize in evaluating and teaching people to read emotions in facial expressions?  Should they be screening us in our competencies?

 

Hospital Intolerance – Peter S. Kibbe, MD, FHM

Recently I was called by an emergency department physician regarding a patient of about ninety years who presented with shortness of breath.  His shortness of breath improved with inhaled bronchodilators but he then developed atrial flutter and due to changes in his ST segments a “code STEMI” was called.  There was a slight elevation of his troponin and the cardiologist arrived.  He wisely demurred, opining that this was not a STEMI but demand ischemia.  His ventricular rate slowed with no particular intervention to about one hundred.  A faint, ground glass pneumonia was apparent in the left upper lobe on x-ray.  He “required” admission for treatment.

He arrived at his room with his wife and son and I arrived shortly thereafter, to find a man who was afebrile, did not appear ill, was mildly cachectic but smiled and made the occasional witty remark.  He was not able to answer questions and deferred to his wife.  He had been short of breath for a day or two, had no serious history of chronic lung or heart disease but was suffering from advanced dementia which included a failure to recognize his wife of over fifty years as his wife and a hallucinatory component in which he asserted that there was another woman in the house. Several months previous to this he had been in the hospital with pneumonia.  She said that she and her son were “trying to care for him at home” but that it was difficult because he wandered and could not sit still and his gait was shaky—they were concerned about falls.

I examined him, reviewed his laboratory data which was benign, looked at his chest x-ray and began to explain what would be done for his conditions when I sensed that something was not right.  His wife was in tears and his son stoically silent with a somewhat pained expression on his face. So I asked, “Tell me what you think of him being in the hospital.  How does he do when he is in the hospital?”

Ask and ye shall receive. His wife told me that the last time he was in the hospital for pneumonia he suffered severely from agitation and required restraints, sedation and the nocturnal presence of family.  The severity of his dementia advanced rapidly and, following discharge, he could no longer recognize her as his wife.  He had been discharged to a nursing facility where the delirium/agitation persisted and she gave me to believe that the experience of hospitalization had caused a rapid deterioration of his primary problem, dementia.

So we broadened the discussion to the family’s goals of care and expectations of medical interventions.  It became apparent that she and her son understood that in caring for him they were in an end game; they wanted to keep him out of the hospital due to its previous negative consequences.  This led to a discussion of palliative care and limiting medical interventions to those measures that preserved his sense of well-being, his comfort and his dignity.  They were in agreement and were happy to discuss what hospice services might offer them.  The hospice nurse arrived shortly thereafter.  I discharged him on an oral antibiotic for what was probably a viral pneumonia.

This is a cautionary tale, in a sense, in that it illustrates how we have evolved a medical practice that processes patients not as individual humans but as potential diagnoses, with our protocols, alerts, codes and order sets.  We do this outside the boundaries of our patients’ larger realities—their frailties, their capacity to consent, their ability to tolerate or comprehend interventions.  We are judged by our algorithmic capacity rather than our capacity to sort out a diagnosis, propose therapeutics and query our patients and families regarding their own capacities to fulfill what is directed by the algorithm.

This man was hospital intolerant and in the end stages of dementia.   How might this 90 year old man  benefit from a real “code STEMI” intervention with catheterizations, stents and subsequent delirium?  We might preserve a myocardium, for good “door to cath lab” time metrics, but offer no benefit to the patient at all.  We must listen.   We must ask.

In Dubious Battle – by Peter S. Kibbe MD FHM

To look upon medicine with a literary eye is something of a burden.  If you have studied poetry, fiction and drama, no matter how much you have forgotten, you find yourself on the wards at times with literary phrases popping into your head that you cannot erase or make silent.  Regarding sitting with a dying patient, “They also serve who only stand and wait,” from a poem by John Milton pops into mind.  Recently, after a grueling day of caring for patients who almost to a person had fatal pathology, the phrase “in dubious battle” came to mind, and the often oxymoronic culture of “health” care as it “brands” itself in America vexed me.

In Dubious Battle is a novel by John Steinbeck.  Steinbeck purloined the title from a phrase in Paradise Lost, the epic poem regarding the biblical fall of man by John Milton.

Paradise Lost is considered by many scholars to be the great epic poem of the modern English Language.  The character of Satan plays a major role, of course, he being the character who will trick Adam and Eve into being ejected from the Garden.  “In dubious battle” is a phrase used by Satan to describe the conflict that he and his band of fallen angels have lost in their conflict with God “in dubious battle on the plains of heaven.”  The mythology is that Satan and co-conspirators in heaven, hating God and detesting his omnipotence, organize an armed uprising, lose and are thrown out of heaven by God.

In the poem, Milton employs oxymorons, a linkage of two ideas or words that are self-contradictory, such as “brilliant darkness.”  The use of the adjective “dubious” by Satan is a nod to the oxymoron, because the entire notion of winning a fight with God is oxymoronic—you cannot win a fight against an omnipotent opponent.

Who cannot, having walked the wards for decades, find the notion, implicit in what we do, of “curing” certain patients, or “rehabilitating” certain patients, as oxymoronic compared to the actual data we must point and click and type into the electronic medical records to describe our patients’ conditions.

We cannot promise health to those whose journey has already taken them beyond its prospect. The obesity epidemic seems to be swelling like a wave, crashing upon those of us who work in the medical field.  The changes of American culture, which I will call pathogenic, have brought us an opioid epidemic and an epidemic of obesity and they are causing our life expectancy to fall. They  germinated during the youth of the baby boomers, coming to full fruition through their lifetimes.  Now these massively obese souls have stumbled into the ranks of the aged and their multiple pathologies and physical impairments tethered to the expected impairments of aging itself kindle storms of acute disease.

I start a morning staring at the chart of a woman with a body mass index of 51. She presents with not one, but several potentially fatal events: her arm is infected; she has acute influenza and an acute exacerbation of her COPD with marked hypoxia.  The patient’s age is seventy-something.  She has had coronary stenting, lived for years with the metabolic syndrome of diabetes, hypertension and hyperlipidemia; she has had breast cancer bilaterally with infectious complications due to lymphedema, cellulitis and secondary bone infection of the spine, requiring months of intravenous antibiotics.  She has suffered from diastolic heart failure and atrial fibrillation as well as chronic obstructive pulmonary disease; and she has chronic kidney disease.

This poor person is in dubious battle.  We know she cannot win and we know that probably many medical adventures await her—those coronary arteries will get gummed up, the kidneys will fail completely and she will need dialysis. Chart review shows that she has been in and out of the hospital frequently over the past couple of years and the gravity of her morbidities appears on an upward curve.

Her aggressive consultants, her family informs me, are contemplating a biopsy of her vertebrae to make sure her bone infection is “under control.” I am fearful that procedure will not go well.

We are not caring for her health but attempting to react therapeutically to her multiple predictable disease states and the pathologies that are not random but rather the complications of a physiological illness for which we have little to offer.  Severe obesity, mixed with aging, is a poisonous cocktail.

I have argued that one of our cardinal failures as physicians is to not honestly give a prognosis. There is a delicate dance in communicating with patients who have multiple smoldering and flaring morbidities and who have a very high likelihood of suffering severe complications and organ failures.  On the one hand, it is not fair for us to maintain a pretense that patients such as the one whose clinical picture I sketched are going to be “cured.”  On the other is the fact that professionally she deserves our empathy and in our communications, verbal and non-verbal, we must attempt to be of benefit. This is, of course, our duty to all patients but we must not forget it in our care of the severely obese or the addicted.

Taking a history from this patient was laborious and somewhat emotional.  She was assisted by her daughter (whose level of involvement in her mother’s medical picture was revealed when she showed me her mother’s X-ray images on her cell phone.)  I find it helpful, when trying to establish a relationship with a patient such as this one, to listen carefully to the story of her medical adventures and then acknowledge that she has had some really difficult encounters with disease over the past several years.  “It sounds as though you have had a really tough time over the past years with these medical problems.”  And then, of course, you have to listen to the response, which might give you a handle on what the patient and family have in terms of expectations.  One can further connect by inviting the patient/family to explain the situation in the context of exactly how she and the family are coping with it—how and where she lives, who helps her, her functional abilities and disabilities.  Being open to this information allows you to “go where the patient lives.”  Doing so makes further conversations (about CPR or other intensive measures if they need be discussed) more contextualized within a relationship you have established.

In explaining what the medical care will be for this person’s acute problems a physician does not need to offer a general prognosis for anything but the acute problems.  Should the medical situation deteriorate, giving as accurate a prognosis as possible may become necessary.  In order to make that easier, establishing a relationship is a crucial step in patient communication.

Listen. Acknowledge.  Listen more. Empathize. If we cast a cold eye on the numbers and ages of people with obesity in America, it is certain that our dubious battle has not yet reached its crescendo.

 

 

By 2020 it is estimated that 75% of Americans will be overweight or obese. 

To read more, see OECD(Organisation for Economic Co-Operation and Development) update from 2017: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf 

 

 

Mismanagement by Metrics – Peter S. Kibbe, MD FHM

Some years ago when I practiced in a rural hospital I was asked to admit a man who had sustained fractures to both knees.  I balked because I knew that the only orthopedic surgeon at the hospital was out of town and the man needed surgery on both knees. Aside from the fractures, he had no medical issues preventing surgery.  Conventional medical wisdom teaches that the faster this sort of injury is fixed, the better the outcome for the patient.  The hospital administrators pressured me to keep the patient “for a few days” until the orthopedic surgeon returned.  Their incentive was clear.  They wanted to capture the operative/financial billing.  My incentive was to get the patient the care he required.  Discussions that ensued between the administrators and me were not pretty.

At times financial and outcomes metrics push in an opposite directions.

I recently came across an interesting article of investigative journalism by Pulitzer Prize writer David Phillips in the New York Times. Phillips describes the complaints of physicians at a small VA hospital in rural Roseburg Oregon. They claim that the hospital administrators frequently denied care to patients who were very ill, sending them home or off to other facilities, in order to make their overall medical care outcomes look better.  If the patients were not admitted, they were off the radar in terms of data analysis.  Any negative outcome of their illness would occur at home or at another hospital.

He describes a set of ‘metrics’ used throughout the VA system to grade hospitals and their associated clinics.  Patients who are very sick and die lower the grade as well as anyone requiring admission for congestive heart failure (the diagnosis implies poor system outpatient management).  Also bringing down the score are patients readmitted within thirty days, hospital acquired infections and so forth.  Phillips reports that there are about one hundred of these metrics that are used to grade facilities.

Curiously, Phillips finds, since the metrics grading system was implemented across the VA system, many facilities have improved their scores.  He interviews doctors who claim this has happened not because of improved medical care but due to the fact that administrators game the numbers by avoiding the treatment of patients who might have poor outcomes.  About half of the beds at the Roseburg VA, he reports, remain empty.

The community of Roseburg is rural and poor.  The unemployment rate is high.  The Roseburg VA Health System, he states, is understaffed and he reports that many of their primary care physician positions are empty, making ongoing care of patients in the system problematic.  The hospital itself has no intensive care unit.  But Phillips interviewed emergency and hospital physicians there who claim they are forced by administrators to turn patients away who could be cared for there in order to play the metrics game. They claim that the administrators want to keep patients with poor prognoses “off the books.” He describes a cachectic veteran in his eighties who presented with dehydration, falls and fractured ribs whom the doctors wanted to admit.  The administrators refused and sent him home.

Given the fact that the community is rural and poor one would expect the disease burden of the veteran population in Roseburg to be high.  So, given the poor staffing, the population, the location, and the demographics, why would distant administrators impose what sound like unattainable metrics on a group of health care workers struggling to provide veterans with care?

And, if you were the local administrator and the administrators above you would reward you if your scores improved and punish you if they did not, would you not manipulate everything you could to make your performance look better? Phillips reveals that administrator’s bonuses go upward with better scores.

This issue of avoidance of ill persons by medical professionals is not at all new.

The problem with evaluations at play in systems such as this is the failure of leadership (administrators) to embrace the reality of the workplace.  From what Phillips reports, Roseburg’s VA facility’s principal and overarching problem is lack of staffing. Until administrators attend to that it is hard to imagine the value of imposing grading systems on teams of workers which are skeletal.

It would appear that the grading system under which it struggles represents an administrative failure.  Expecting excellent medical outcomes in attempting to appropriately treat aging, rural veterans with multiple morbidities is a fool’s errand which fails the patients.  The doctors think it is actually diminishing the quality of their care by administrators who do not want physicians  to care for them in the hospital at all. The doctors he interviewed seemed to be saying, “Let us do our jobs and do what we can for these fragile and sick people without sending them many miles away from their families.  Some of them might die because some of them have fatal illnesses, but metrics should not be part of the decision to care for them here or transfer them out.”

In my experience I have found that physicians generally, in keeping a patient at their facility or seeking a transfer to a higher level of care, do so with the best interest of the patient in mind. The questions involved include whether the patient would benefit from care not available at his/her present facility, and whether the patient wishes to experience that higher level of care.  Hospital administrators can push and pull that decision in both directions depending upon their incentives.  I would argue that the decision should be medical.

Administrators, in most of these decisions, lack the license, the agency and the ultimate responsibility for these decisions.

We Are Not… -Peter S Kibbe, MD FHM

One often hears or participates in a political discussion about a problem we suffer in the United States which appears to have been improved or solved in another nation.  One side proposes that we adopt what country X has done to solve our problem.  The other side often counters with what is really not an argument but a non sequitur stating, “We are not country X.”  While true that we are not country X, the fact that we are not is an invalid argument within debate.  Embodied in that statement however, is the notion that:  a) we are unique and special, b) we are incapable or politically incompetent to confront the issue, or c) the problem is highly damaging to most of us but is producing great sums of money for a few individuals, and well… “We are not country X.”

I point this out as preface to a discussion of the success of the relatively poor country of Portugal in addressing its opiate abuse epidemic.  Their results in dealing with their own epidemic of opiate-related deaths has been only superficially exposed and virtually ignored by our corporate media. Yet from Portugal’s example we might learn striking and relatively simple lessons to put a halt to our opiate-related epidemic of death, and curb the associated medical pathology and social pathology.

During the 1990’s Portugal saw a rapid increase of opiate addiction and opiate-related deaths, mostly from intravenous heroin use, along with a striking increase in HIV and hepatitis transmission related to the same.  Their death rate climbed to twice the rate for European countries in general.  I have read estimates that one percent of their population suffered from addiction, perhaps more. From accounts, their problems with opiate addiction were almost a prelude or foreshadowing of what we are experiencing today in the United States.

In 2001 Portugal responded to their epidemic by decriminalizing the possession of relatively small amounts of illegal drugs. It has been reported that they consider possession of approximately ten days’ worth of drugs for a person to be a non-criminal offense, but they did not legalize the possession.  Possession of the small amounts of certain drugs remained an administrative offense and manufacturing or selling illegal drugs and trafficking remained criminal offenses.

The majority of addicts were thus removed from the criminal system of courts and prison sentences and therefore the society at large was spared these costs.  Persons found to have small amounts of illegal drugs were referred to administrative committees for evaluation.  These committees consisted of a representative of social services, a person from the legal system and a physician.  The committee retained punitive measures it could bring to bear against these persons, but these did not include prison sentences.  The committee is tasked with assessing the person and suggesting a treatment modality.  If the person does not comply, he/she could suffer various penalties such as forfeiture of licenses related to work.

At the same time Portugal established a free system of treatment centers, some public and some private, that promoted harm reduction, some social services and conversion to medical replacement therapy. They included inpatient services but the bulk of their treatment facilities were for outpatients.

Their success in reducing drug-related death rates over a few years was stunning.  Portugal joined the three lowest death rate countries in Europe.  Rates of HIV and hepatitis transmission also declined dramatically.  The rates of opiate and other drug addictions do not appear to have changed, but this part of the epidemiology is difficult to assess due to the fact that their policy changes made it much easier to count the number of addicts out there once many of them were offered free treatment.

I am not able to comment on the financial costs of this change of policy in Portugal.  There was a savings, no doubt, from not having to support the cost of the courts and incarceration which we continue to sustain in this country.  There was a cost to establish medical facilities for treatment.  Were we to emulate Portugal I suspect we might actually see a net savings, given that within our prison-industrial complex we are currently spending tens of thousands of dollars a year to incarcerate addicts. It would be difficult to quantify the dollars saved by decreasing the social costs of our addiction epidemic—the costs of social services for the foster care of children with addicted parents, the medical costs of the complications of intravenous drug abuse, the EMS costs of dealing with overdoses and so forth.  Political push-back would, no doubt, be strong from the for-profit prison corporations in the United States and assuredly from other entities that directly or indirectly profit from the status quo.

What the Portuguese did was to take the problem out of the system of criminal justice and to treat it as a medical and social problem. There are many reports of entities such as local criminal courts attempting basically the same thing in the United States but clearly we need to change on a national level. For years now our “war on drugs” has failed and criminalization of addiction has failed.  Both have cost us phenomenal amounts in terms of social disruption and pathology, to say nothing of the fortunes sunk in failing policies and policing.  The profits related to these policies have gone to pharmaceutical giants, the private prison-industrial corporations and to cartels of traffickers in illegal substances.

 

Portugal, a much less wealthy nation than our own, has created solutions which we, with much more in the way of fortune and resources, should emulate.  The morgues here are bulging.  Death rates continue to rise.  “We are not Portugal” is an insufficient statement regarding our inertial present posture.

 

 

 

 

Clarity & Craftsmanship – Peter S Kibbe, MD FHM

As Director of Patient Experience in our group of physicians, my job is to promote better patient communication. However, it increasingly appears to me that physician to physician communication is generally deteriorating and in need of remediation as well. Perhaps as my years advance I am forgetting that poor communication has always existed. Please help me out: are a lot of medical people speaking gibberish today, or is it just my imagination? As a group of hospitalists, we care for patients in the hospital. We admit patients into hospital beds principally after they have been evaluated and treated in the emergency department of our hospitals, but we also receive them from other emergency medical facilities, clinics and doctors’ offices.

Historically when these transfers occur it is convention that the referring physician verbally “presents” the patient case to the accepting physician. This allows the accepting physician to establish the seriousness of the illness, to be sure that the hospital where we practice has the capacity to care for the patient’s illness and to establish what kind of medical floor the patient will re-quire(intensive care, regular medical floor, monitored bed) and so forth.

And, time out of mind, this presentation of the case by the referring physician has been an important expression of the craftsmanship of the referring doctor. What he or she says proves that she knows why the patient has been brought to a doctor, who the patient is in terms of age, chronic and past medical problems, what the patient exhibits on physician examination, and what, if any, laboratory studies and imaging studies show. This usually includes a description of what treatment has been rendered.

Just last week I received a call from a physician at a clinical location outside the hospital, to accept a transfer to our hospital of a man this physician was evaluating. The physician was clearly a native English speaker but after several minutes of listening to him I had no notion of who the patient was or why he was being transferred to me. I knew I was in trouble when the referring physician began with an introduction, “Well, I have a guy here who, I don’t know, had a fever and, well, maybe there is a pneumonia….his white count is 24 thousand…He played eighteen rounds of golf yesterday and then felt bad…”

This frustrating, unorganized “hand-off” conversation degenerated into a sort of game of twenty questions. I had to ask the patient’s age, race, current medical problems and whether he was diabetic (the physician did not know). The physician gave me the laboratory and imaging data before telling me about the findings on physical examination. There was talk of fever and a pos-sible pneumonia. I concluded by simply accepting the patient after determining he could go to a regular medical floor.

When I went to see him and asked him what was troubling him his wife told me he had a recurrent soft tissue infection in his leg. He was a morbidly obese, insulin resistant diabetic with hypertension and obstructive sleep apnea and a body mass index of forty five. He was hospitalized two years ago for cellulitis of the right leg. And, indeed, he had a swollen and erythematous right leg.

This sort of communication failure seems to be happening to me more frequently. The following day I was called to accept a patient from an emergency facility because she used heroin and needed to have an observation admission to rule out bacterial endocarditis. Not only did she have no complaints to suggest bacterial infection, she had never used intravenous heroin. She had a long history of ingesting heroin via the nasal route, but never had used a vein. I could imagine sinusitis secondary to heroin inhalation, but endocarditis?

These frustrating hand-off encounters suggest that the basics of practice are being ignored. The basics, of course, include the step by step process of evaluating a patient—the reckoning of who the patient is, what chronic and past medical conditions exist, what the complaints are, what the physical findings are, then what the laboratory findings tell.

This process is then articulated by verbal presentation of the patient to another physician. That presentation is effective only if the information within it is accurate and also has coherence. So the first patient I mentioned above can be medically described well in a couple of sentences: “This is a 68 year old, very morbidly obese, white, male, hypertensive diabetic with a complaint of malaise and fever.” When one hears that last sentence one has an immediate picture of the “who” of the patient, at least in the medical sense.

I would also urge colleagues to consider including in that first sentence any information that medically defines the patient. If a patient suffers from a severe cardiomyopathy, or is being treated for a malignancy, or has a major ongoing series of morbidities, those should appear in the opening first or second sentence. “This is an 85 year old with advanced dementia, DNRCCA status and an ejection fraction of 25 percent who was brought to the hospital due to fever from the nursing facility where she is a resident.” I find that more typically when an ED clinician calls regarding that same person, I am told about an 85 year old patient with fever and a urinary tract infection and a high white blood count. Verbally expressing the “who” of the patient is critical to better communication. It is essential to treating people rather than processing patients.

The issue of the heroin addict implies poor patient communication but also implies that she was evaluated without the craftsmanship demanded by competent practice. If you are practicing in an emergency facility, particularly one in a state and nation known for its huge epidemic of deaths from opiate abuse, you have to be able to have a competent conversation with people who use opiates. That includes finding out their method of ingestion—prescriptions, intravenous ingestion or nasal ingestion; one of the oldest methods of ingestion is to smoke it. You need to know how often they need to take it to avoid withdrawal. Then you can employ “harm reduction” strategies which include questions about needle exchanges, Narcan availability, instruction about the safest ways to injectand also question the patient about previous rehab attempts, street Fentanyl issues and ask for a social service consult regarding treatment venues for the patient. (see SHM’s website:
http://www.hospitalmedicine.org/Web/Quality___Innovation/Implementation_Toolkit/Radeo/radeo_home.aspx  

This particular patient who regularly used opiates was fully employed, demonstrated insight into her addiction, recognized that at this point she was  using heroin pretty much to avoid withdrawal symptoms and had been thinking of finding some treatment options to “get clean.” She “used” several times a day. Since she had spent about twelve hours within the other hospital and our own it was pretty clear that she was dosing herself while in the hospital and she had no withdrawal symptoms.

As I listened to her describe the symptoms that had brought her to an emergency department in the first place(which were fairly trivial) and heard what she had to say about her life it struck me that subconsciously she was most likely looking for some help with the primary problem of her life, opiate dependence. Sadly our society has this problem in spades and our medical /social system seems flummoxed about what to do with it. We are unable to employ models successfully employed in other countries, but that is the subject of another of my screeds and tirades. In any event, her “who” was much more in need of some counseling and support than blood cultures and antibiotics.

Anchors Away

Anchors Away – Peter S. Kibbe, MD FHM 

A fifty-six year old woman is brought to the emergency department because she exhibits confusion.  She is accompanied by her elderly mother who does not see her often but has on the day of her presentation randomly tried to communicate with her and found her confused.  The mother cannot contribute much regarding anything else but knows she has been in good health and knows she does not smoke but thinks she drinks alcohol frequently.  The patient exhibits mild confusion but is fully oriented.  She seems to have memory impairments.  She appears to have no focal neurological complaints.  Her blood alcohol level is 0.08 gm per deciliter and a CT of her head reveals no acute lesions.  She is afebrile and a CBC and basic metabolic panel are unremarkable.  Her symptoms are attributed to ethanol and she is discharged.

En route to her mother’s car she suffers an event involving a fall.  She appears unhurt.  She is returned to the emergency department and admitted with a suspicion of alcohol withdrawal and possible seizure.  She was admitted by a hospitalist and evaluated by a neurologist.

Eight hours later she is found by the rounding hospitalist to have an expressive aphasia and a right homonymous hemianopsia.  She is fully cooperative.  She has a slight fever.  An emergency lumbar puncture reveals lymphocytosis and is positive for herpes simplex antigen.  Appropriate antivirals are administered.  She recovers after seven days.

A forty-two year old woman presents to the emergency department with subacute abdominal pain.  Her urinalysis reveals leukocytes and she is treated for a urinary tract infection and released.  She returns after seven days complaining of abdominal pain, is found on urinalysis to again have leukorrhea and a CT of the abdomen is obtained and is negative.  The hospitalist is called to admit her for a urinary tract infection that has failed outpatient management.  She arrives at the floor.  On questioning she complains of a month of progressive epigastric pain exacerbated by food.  Her physical examination reveals marked tenderness to palpation in the epigastrium.  Upper endoscopy the following morning reveals a large and deep gastric ulceration.

A sixty-one year old nursing assistant presents with right upper quadrant pain of sudden onset following the ingestion of a fatty meal.  She has had two episodes of alcohol related pancreatitis, the last nine months previous, after which she gave up all alcohol ingestion.  A CT of the abdomen reveals a pancreatic cyst, slightly larger than when seen before.  Her serum lipase is normal.  She is admitted for acute pancreatitis.  When she is examined on the floor she reports the pain has improved.  Her examination reveals marked tenderness in the right upper quadrant.  She describes her pain from previous pancreatitis to have been different-epigastric with radiation into the back.  When asked what she thinks is causing her pain she says that she thinks this must be her gall bladder as she had a similar and brief episode two weeks ago after eating fried chicken. Ultrasound of the gall bladder confirms biliary sludge and wall thickening.

“Anchoring” is broadly described as a cognitive bias that occurs in decision making.  It is a cognitive event dependent upon the human tendency to rely too strongly on the first piece of information that is offered in a decision making task.   Each member of the team then reinforces this error, in writing and verbally.   Unless a member of the team is contrarian enough to fully reevaluate the data and repeat investigations, the error anchors the problem into the wrong solutions. So in all three of the above scenarios we see a “first thing” offered— a urinary infection, an alcohol related problem and a pancreatic problem—that anchors the decision making process.   In medical care I would argue it can then propagate through “groupthink” in which members of a group find it easy to accept things that are not necessarily true to minimize their cerebral work and to keep themselves in the majority—to conform.

Anchoring, in my view, is a common threat to patient safety.  It usually is markedly exacerbated by inadequate information gathering, inadequate physical examination, a failure of deductive reasoning, a comfortable emphasis on the importance of laboratory tests or imaging, or a combination of all of the above. 

In the first case, assuming the patient had an alcohol related problem was contrary to her examination and was based on inadequate information. Many people drink alcohol frequently and are not sick from it.  On examination she was muscular, healthy appearing, well kept and not confused but rather having trouble with her speech.  Some people addicted to ethanol do consume enough to give them withdrawal symptoms and are good at hiding it and appear healthy.  But the evidence for this lady having symptoms due to withdrawal were pretty flimsy.  She had no tachycardia or tremor.  She had no stigmata of liver disease.  Her ethanol level was consistent with the ingestion of perhaps two cans of beer.

In the second case there was an inadequate history obtained and the physical examination was superficial.  The diagnosis of urinary infection was made on the basis of a lab test and not on urinary symptoms (asymptomatic bacteruria.)  Going with that handle, that anchor, is so very tempting because it finalizes the work, ends the intellectual chore of actually listening to the patient and hands off the problem.

In the third case there was a failure of “all of the above.” These are the worst. And it is embarrassing when the patient herself ends up telling you, twelve hours after admission, having been examined by two physicians, what the correct diagnosis is.

Groupthink

This is a form of thinking within a group of people in which dysfunctional decision making occurs as a result of the group’s desire for conformity.  Why the group favors conformity can be multi-factorial, but often it involves devotion to the leadership’s thought process.  In this process the group tends to throw out data that conflicts with their view of reality and isolate dissenting voices

This is one of the problems to which medicine is not at all immune.  The opiate addiction crisis is in part to blame on a dysfunctional thought process, to which multiple medical professionals succumbed, and which became a type of thought conformity which went unchallenged in large segments of the the medical establishment.  This was the unproven supposition that people with chronic pain cannot become addicted to opioids.

Anchoring I suspect can also be engendered by the protocols in place to identify stroke and sepsis in hospitalized patients.  When sepsis or stroke alerts are called, the symptoms or signs the patient is exhibiting have now been “anchored.”  Clinicians need to be wary.

Probably the best antidote to the anchoring process in medical thinking is the mature ability to constantly hold a diagnostic assertion in the mind while at the same time subjecting it to doubt.  What one also sees in some very skilled clinicians is a profoundly humble attitude in communication with other professionals, a sincere posture of welcoming critique, a “Please tell me when you think I am wrong” posture in discussing diagnosis and therapy.  This is a humbling job.  “Pride goeth before the fall.”

 

 

 

 

 

Smog at the Economic Level

September 27, 2017

A piece of black humor I hear often uttered regarding patient satisfaction surveys is the hope that the patient survey does not arrive at the same time the hospital bills start to appear.

Humor thrives on recognition and examination of the absurd.  Who has not received a medical bill that appears absurd? A page filled with descriptions and explanations are all quite mysterious, even to physicians.  We puzzle over pages listing inscrutable procedures, descriptions of co-pays, explanations of family and individual deductibles, cost of procedures, insurance adjusted price, amount billed to insurance company(but  awaiting final determination).

The standard hospital bill delivers complexity upon complexity, to say nothing of various errors that can occur.  Once it took almost a year to convince a local hospital that the reason my insurance company was not compensating them for my wife’s major procedure was because they were billing it incorrectly with a cosmetic procedure code.  Actually, it was my office manager who spent hours on the phone, month after month, until someone on the other end awakened from a computer screen induced stupor and billed the event correctly.

Our American medical care “system” has become rife with what some economists call “economic pollution.”  The insurance realities for almost everyone change quickly as employers switch carriers to save costs.  Insurance carriers amend rules incessantly as they alter costs and benefits to maintain profit.  Individuals who purchase their own insurance jump from plan to plan  as costs go up. There are so many variables and pitfalls that the entire system is burdened with clerical costs that consume massive amounts of time and money. The confusion inherent in the system makes the analogy to smog warranted.  One can hardly see the economy of the process for the smog of changing and flummoxing economic rules that enshroud it.

For practitioners it means massive costs in overhead and hiring staff that can work to collect fees from the various entities that insure us.  For many patients who have insurance the system is so complex that they cannot comprehend it.

Sadly, for many insured patients, the one thing they do comprehend is how precarious they are in terms of health insurance.  If they lose a job, they lose insurance and perhaps a chronically ill spouse dependent on that insurance will go without medical care.  Or they know that even though they are insured, they really cannot go to a doctor because the deductible portion of their coverage is something that would financially drown them. Frequently we meet patients who are insured but cannot afford the prescribed medications, such as the best inhaled bronchodilators or most advanced insulins. Medicaid is now available in many states to people with very modest incomes, not available in others.  The system is labyrinthine and laden with economic smog. A large percentage of patients with Medicare are in “managed care” plans administered by the insurance giants, changing the rules frequently and always seem to be merely government-sanctioned middle men extracting a rent from the system.  We have all dealt with the wrenches they can throw into care plans to maintain their profit margins.

One of the very important skills in patient communication is the art of dealing with patient anxiety and fear.  When that fear is economic, how do we deal with it?  Recently I worked with a patient hospitalized for acute manifestations of what appeared to be chronic conditions of which he had been totally unaware.  He was eligible for Medicare, his wife was not.  She had chronic medical problems which were covered by his employer’s insurance.  As I tried to explain his conditions he warned me that he could not stay in the hospital for fear of losing his employment, thus losing the insurance he depended upon to care for his wife.  He assured me he could not afford to purchase insurance for her as an individual.

Thus his anxiety was something of a cascade, moving from economic insecurity to personal anxiety regarding his diagnoses and his job, to spousal and familial anxiety regarding the care of his spouse.  How do I communicate with him regarding that?

First I think it is crucial not to deny that the anxiety is real and understandable.  To admonish him for not focusing on his own well-being, to assure him that “something could be worked out” or to shame him for not addressing his own medical problems before they became so acute would not be in any way helpful or therapeutic.  Acknowledgment that he had a situation that would make anyone worried and anxious would be truthful and empathic.  Saying something like, “I see you have a real dilemma facing you at this point that would make anyone worried” would be a good start to exploring what his options might be.  The next step might be to assure him that we, the hospital, would try to help him sort out his options regarding insurance, putting a consult and call to the social worker who could help him understand what might happen to him and his wife if he lost time from work, lost his job or became disabled.

There may be no happy ending to these troubles.  The fortunes of many of our patients are dashed upon the rocks by the smoggy winds of the “system.”  It is foolish to to deny that financial anxiety is a vicious partner to the other anxieties our patients face..  Sometimes getting that anxiety out onto the table and being  empathetic about it is the best we can do to help our patients along their journeys.

 

Cleveland: One of Forbes Top 25 Cities…

Cleveland has a lot going for it:  A great place to live and raise a family.  Lots of parks and scores of outdoor activities.  Championship basketball, renowned symphony orchestra,  art Museum, theater district….and much much more!  But Cleveland also sits as #4 on Forbes’ “Top 25 Cities Where Your Paycheck Goes the Furthest”  Cleveland, home of  world class patient care, is kind to your pocketbook, which helps to payoff  those #student loans.  Find out more about what makes Cleveland – and Martin Healthcare Group, such an outstanding choice.